Signs and Symptoms
Multi-eared stethoscope, state of the art, circa 1940
Sir William Osler (1849-1919) is widely acknowledged as the father of modern medicine. He was one of the four founders of the Johns Hopkins Hospital, was instrumental in creating the first residency program for training specialist physicians, wrote The Principles and Practice of Medicine* and brought medical students out of the lecture hall to the bedside. He was a staunch advocate of the clinical examination and interacting with patients, to the degree that he famously said, He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all. By their third year, Johns Hopkins medical students were taking histories, performing physical examinations, and doing lab tests on sputum, blood and urine.
*Which saw multiple editions and remained in print for nearly a century.
The state of medicine in Osler’s era seems quaintly primitive compared to that of today. Diagnostic imaging modalities that we now take for granted–ultrasound, CT, MRI, and PET, were decades in the future. The same could be said of preventive and therapeutic medicine: vaccines, corticosteroids, antibiotics, and chemotherapy. Osler urged students to listen to your patient he is telling you the diagnosis. Things have changed. Modern diagnosticians rely far less on often subjective findings obtained by examining the patient and more on the objective data provided by lab work, biopsies and imaging reports.
Young doctor explaining (objective) lab results. The stethoscope proves she’s a doctor
Old school clinicians and seniors alike complain that today’s medical students and residents no longer properly examine their patients, but have their noses buried in the most recent blood work and X-rays. The loss of trainees’ ability to recognize classic signs and symptoms of common conditions is a regular topic in peer-reviewed journals and fora. Too often one reads about the waning art…the dying art…the lost art of physical examination at the bedside.
The question is, is the clinical examination an art that needs preserving or is its demise a natural progression of medicine?
As a non-clinician, I find it comforting to believe that a skill that I never learned well is shrivelling on the vine and losing its relevance to modern medical practice, regardless of one’s specialty. When classic findings in clinical medicine are compared to objective diagnostic tools, they fall short. A small cohort of patients admitted to a Veterans Affairs emergency room were examined by three clinicians and compared to the gold standard, the chest radiograph. The sensitivity of the clinical diagnosis ranged from 47% to 69%, and the specificity from 58% to 75%. In a 1992 study at Duke, 63 residents in internal medicine were asked to listen to heart sounds programmed into a mannequin. Half of those tested couldn’t identify aortic regurgitation or mitral regurgitation; two thirds missed mitral stenosis. In a further study from the same group, residents were compared to medical students in identifying 12 different heart sounds recorded from real patients; both groups correctly identified only 20% of the sounds (for the record, the residents did slightly better than the medical students). Studies of their auscultation skills were just as abysmal.
Evidence-based scrutiny of the so-called classic findings of well-described clinical conditions too often fall short, precluding a definitive diagnosis. Examples of classic signs and symptoms, which aren’t particularly useful for diagnosing the disease for which they were regarded as typical:
• Charcot’s triad–dysarthria, nystagmus, and intention tremor, regarded as typical of multiple sclerosis
• Lucid interval in subdural hematomas
• Pulmonary thromboembolism is underdiagnosed given the lack of the classic signs of dyspnoea–seen in 59%, chest pain–17%, and haemoptysis–3%
This section includes a sampling of signs and symptoms found in major medical dictionaries…even if you won’t find them in a patient.